HospitalInspections.org

27382


* The facility failed to maintain the piped in medical gas system. See example:

2) The annunciator located at the nursing station for the piped in medical gas system was observed not working.

Signed contract was provided indicating replacement of several components to O2 piping.

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1999 NFPA 99, 4-3.4.1.1* General. Inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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* The facility failed to provide an emergency generator annunciator. See example:

A remote annunciator was not observed provided at any location within the facility for the emergency generator.
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1999 NFPA 99, 3-6.1.1 Generators shall conform to 3-4.1.1 1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station.

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]